i schriften 1 reihe nr. 112

H
ISSN 0933-050 X
IINIGUNG AUTOMOBILTECHNIK EV
i
I SCHRIFTEN
1 REIHE NR.112
Bewertung epidemiologischer
Untersuchungen über
Dieselmotorabgas und
Lungen- und Blasenkrebs
- Kritische Übersicht -
On the Epidemiology of Diesel-Exhaust
and Lung and Bladder Cancer
- A Critical Review -
Bewertung epidemiologischer Untersuchungen über
Dieselmotorabgas und Lungen- und Blasenkrebs
- Kritische Übersicht -
On the Epidemiology of Diesel-Exhaust and
Lung and Bladder Cancer
- A Critical Review -
Auftraggeber:
Forschungsvereinigung Automobiltechnik e.V. (FAT)
Contractor / Auftragnehmer:
Professor Dr. Ernst L. Wynder
Authors / Verfasser:
Prof. em. Dr. I.T.T. Higgins, University of Michigan;
Dr. R.E. Harris, Ohio State University;
Prof. Dr. E.L. Wynder, American Health Foundation
Postanschrift:
Postfach 170563 • 60079 Frankfurt
Telefon (069) 7570-1
Drahtanschrift: Autoverband
Telex 411293
Druckerei Henrich GmbH
Schwanheimer Straße 110
60528 Frankfurt am Main
Vervielfältigung, auch auszugsweise, nur
mit ausdrücklicher Genehmigung der FAT
VORWORT
Seit ihrer Gründung im Jahre 1972 ist die FAT bestrebt, die Zusammenhänge zwischen
Automobilabgas und Ökologie und menschlicher Gesundheit zu klären. Sie hat deshalb eine
Reihe von Forschungsvorhaben initiiert, Mittel für die Finanzierung beschafft und die Forschungsnehmer bei der Bearbeitung der Projekte durch die Mitglieder ihres Arbeitskreises 1
'Auto und Umwelt', die im Anhang namentlich genannt sind, betreut.
Nachdem sich herausgestellt hat, daß Ottomotorabgas in der Atemluft auch in den höchsten
darstellbaren Konzentrationen zu keinerlei Tumoren in der sehr empfindlichen Rattenlunge
führt, wie im FAT-Projekt Nr. 55 nachgewiesen wurde, sind Untersuchungen über den
Zusammenhang von Dieselmotorabgas und Lungenkrebs immer mehr in den Mittelpunkt der
Abgaswirkungsforschung gerückt.
Zur weiteren Untersuchung dieser Zusammenhänge wurden kürzlich bei neuen Inhalationstests Ratten und Mäuse im 'in-vivo Verfahren' einer mit Dieselmotorabgas und inertem
Staub belasteten Atmosphäre exponiert (Schriftenreihe Ökologische Forschung des Bundesministers für Forschung und Technologie: Auswirkungen von Dieselmotorabgasen auf die
Gesundheit', 1992). Die Ergebnisse zeigen, daß
- es sich bei den aufgetretenen Lungenschädigungen um einen rattenspezifischen
Effekt handelt: bei anderen Tierarten sind derartige Effekte nicht aufgetreten.
- für Lungenschädigungen mit hoher Wahrscheinlichkeit ein KonzentrationsSchwellenwert an Partikeln überschritten sein muß. Tumoren sind auch bei
Ratten nur bei sehr hohen Abgaskonzentrationen aufgetreten.
- Dieselruß und inerter Feinstaub gleichermaßen wirken,
- die Dieselruß- bzw. Staubpartikel selbst und nicht die angelagerten Kohlenwasserstoffe die gesundheitsschädigende Wirkung ausüben.
Um die Übertragbarkeit dieser Ergebnisse auf den Menschen zu klären, werden epidemiologische Untersuchungen durchgeführt, obwohl diese Verfahren große Fehlerquellen in sich
bergen.
Epidemiologischen Untersuchungen sind besonders aufwendig, weil hierbei eine große Anzahl von Personen und deren Lebensgewohnheiten über eine längere Zeit beobachtet und
bewertet werden muß. Deswegen sind auch die epidemiologischen Erkenntnisse oft mit
großen Unsicherheiten behaftet, den bei längerer Beobachtungsdauer können leicht Fehler
auftreten, weil die Belastungskennwerte in der Regel nicht eindeutig ermittelt und Zusatzbelastungen oft nicht erkannt werden. Bei bestimmten Eigeninteressen der Versuchspersonen
werden bewußt oder unbewußt falsche Angaben, z.B. zu den Rauchgewohnheiten gemacht,
was die Aussagefähigkeit der Untersuchungen weiter verringert.
Wegen dieser Unwägbarkeiten und der vielen möglichen Fehlerquellen hat die FAT darauf
verzichtet, eigene epidemiologische Untersuchungen durchzuführen. Sie hat jedoch Prof. Dr.
Wynder, Direktor der American Health Foundation, New York, einen durch zahlreiche
grundlegende Arbeiten ausgewiesenen Epidimiologie-Experten, gebeten, die Aussagefähigkeit und statistische Gültigkeit der Ergebnisse aus bereits abgeschlossenen epidemiologischen
Untersuchungen über den Zusammenhang zwischen Dieselmotorabgas und Lungenkrebshäufigkeit beim Menschen zu bewerten.
Herr Professor Wynder bestätigt, daß es nicht möglich ist, die Belastungen einer Versuchsgruppe und einer Kontrollgruppe von Menschen hinreichend genau zu bestimmen.
In vielen Fällen werden die fehlenden Daten durch Interpolationen und Erfahrungswerte ersetzt, was zwangsläufig zu Fehlinterpretationen der Ergebnisse führen muß. Trotzdem wird in
letzter Zeit die Einführung verschärfter Grenzwerte für die Emission und Immissionen von
Dieselpartikeln mit den Ergebnissen aus epidemiologischen Studien begründet. Diese Politik
birgt jedoch die große Gefahr, daß Belastungs- und Umweltschutzgrenzwerte aufgrund wissenschaftlich nicht abgesicherter Erkenntnisse festgelegt werden. Die hier vorgelegte Bewertung der zur Frage der Wirkung von Dieselmotorabgas auf die menschliche Gesundheit
durchgeführten epidemiologischen Studien macht diese Problematik sehr deutlich. Bei keiner
Untersuchung konnte die durch Dieselmotorabgase verursachte Belastung der Atemluft
exakt bestimmt werden, weil immer weitere, z.T. größere Einflußfaktoren erkennbar waren,
aber nicht bewertet werden konnten. Hier ist vor- allem der Einfluß des Rauchens entscheidend: er kann nicht sicher korrigiert werden.
Mit dem Ziel, die Originalbewertungen der Forschungsnehmer zu den einzelnen Studien
bekannt zu machen, hat sich die FAT entschieden, den Bericht in Originalfassung, d.h. in
englischer Sprache zu veröffentlichen und so den Interpretationsspielraum eng zu halten und
Übersetzungsungenauigkeiten zu vermeiden.
Die Autoren folgern, daß die von ihnen geprüften epidemiologischen Studien keine lungenkrebserzeugende Wirkung von Dieselabgas nachweisen können. Allen angeblichen Nachweisen fehlt die überzeugende statistische Aussagekraft.
FORSCHUNGSVEREINIGUNG AUTOMOBILTECHNIK EV (FAT)
Frankfurt am Main, im Juni 1994
Inhaltsverzeichnis / Contents
Seite
Zusammenfassung
1
Abstract
2
Introduction
3
Relationship between Diesel exhaust exposure and lung cancer
5
Relationship of Diesel exhaust exposure to bladder cancer
18
Acknowledgements
29
References
31
Table 1 : Smoking habits by occupational group
37
Table 2: Lung cancer risk and employment in occupations
associated with exposure to Diesel emissions
38
Addresses of authors
39
Mitglieder des FAT-AK 1 'Auto und Umwelt'
41
Zu sammenfassung :
Die wichtigste Ursache für Lungen- und Blasenkrebs ist das Rauchen. Auch eine Anzahl von
entsprechenden krebserzeugenden Arbeitsstoffen ist eindeutig bekannt. In dieser Studie soll die
Frage untersucht werden, ob die übliche Luftverschmutzung und insbesondere die Abgasemission von Dieselmotoren das Risiko für Lungen- bzw. Blasenkrebs erhöhen kann.
Dieselabgas hat im Tierversuch nur bei der Ratte - nicht bei Hamster und Maus - dann Krebs
erzeugt, wenn es in sehr hohen Dosen verwendet wurde. Die Übertragbarkeit von solchen
Versuchsergebnissen vom Tier auf den Menschen ist unsicher, da neben dem Speziesunterschied auch zu berücksichtigen ist, daß der Mensch selbst unter sehr ungünstigen
Bedingungen einer viel geringeren Dosis ausgesetzt ist.
Bei epidemiologischen Studien zur Wirkung von Dieselabgas treten grundsätzlich 3 Probleme
auf:
1. es gibt keine eindeutigen Meßgrößen für die Belastung der untersuchten Bevölkerungsoder Berufsgruppen mit Dieselabgas
2. es ist äußerst schwierig, die Hauptursache dieser beiden Krebsarten, nämlich das Rauchen,
quantitativ zu berücksichtigen
3. es gibt bei Ursache / Wirkung-Verknüpfungen starke Vorurteile
Viele Studien zum Zusammenhang einer realen oder vermuteten Belastung durch Dieselabgas
mit Lungen- bzw. Blasenkrebs haben den Einfluß der Hauptursache, also des Rauchens, völlig
außer acht gelassen. In dieser Arbeit wird nachgewiesen, daß die Rauchgewohnheiten bei
verschiedenen Berufsgruppen stark voneinander abweichen. Epidemiologische Studien, welche
den Einfluß der Rauchgewohnheiten berücksichtigen wollten ,taten das nur für die wichtigsten
Unterschiede. Sie ließen viele andere Einflußmöglichkeiten des Rauchens unberücksichtigt, die
jedoch das Krebsrisiko beträchtlich erhöhen können. Auch eine angemessene Berücksichtigung anderer verfälschender Einflüsse gelang bisher nicht. Diese Fehlerquellen müssen
das Ergebnis epidemiologischer Studien immer dann besonders beeinflussen, wenn der
untersuchte Zusammenhang von Ursache, z. B. Dieselabgas, und Wirkung, z. B. Lungenkrebs,
nur schwach ist.
Die wichtigen epidemiologischen Studien zu Dieselabgas wurden in dieser Arbeit kritisch
geprüft. Die Autoren kommen zu dem Schluß, daß keine dieser Studien an belasteten
Arbeitsplätzen ein eindeutig erhöhtes Risiko für Lungen- bzw. Blasenkrebs durch Dieselabgas
nachweist. Die Ergebnisse dieser Studien zeigen unter den Randbedingungen der
epidemiologischen Möglichkeiten, daß ein derartiges Risiko wahrscheinlich nicht existiert.
Abstract
Cigarette smoking is the most important cause of lung and
bladder cancer.
known.
A number of occupational carcinogens are also well
The question whether general air pollution and specifically
diesel exhaust emissions increase the risk of these two types of
cancer is less certain.
Diesel exhaust emissions have produced
cancers experimentally in animals when administered in very high
dosages, but the relevance of such experiments to man, exposed even
under the worst conditions to very much lower dosages, is
uncertain.
The problems with regard to diesel exposures in man are
first that we do not have any very good objective measurements of
diesel exposures; second, that i t i s very difficult to allow
adequately for the major risk factor of these two cancers, namely,
cigarette smoking; and third, that there are powerful inducements
towards biased ascertainment.
Evidence is presented that smoking
characteristics vary greatly in different occupations.
Many
studies of diesel (or suspected diesel) exposure in relation to
lung and bladder cancer have not considered smoking at a l l .
Those
that have, have often considered only major differences in habits
and ignored many other aspects of smoking, which may considerably
increase carcinogenic risk.
The main epidemiological studies
considering diesel exhaust emissions in relation to lung and
bladder cancer are c r i t i c a l l y reviewed.
Our conclusion is that any
increase in the risk of lung or bladder cancer from current
exposures to diesel exhaust emissions cannot be large and may
indeed not exist.
Adequate allowance for other confounding factors
has not yet been achieved.
Introduction
The true relationship between an environmental factor and a
disease may be obscured in a number of ways.
The most important
problems that need to be considered are: case/control selection,
confounding by one or more factors having similar effects, biased
ascertainment of the data, and the choice of inappropriate subgroups for comparisons.
These factor, always matters for concern,
become particularly troublesome when the association being sought
is weak, that i s , one that increases risk by three-fold or less.
In these circumstances sound judgement becomes crucial if
conclusions are to be avoided (1-5) .
false
There have been several
reviews of diesel exposure and health effects, especially lung
cancer (6-13).
In this paper we review the evidence on the
relationship between exposure to diesel exhaust emissions and the
occurrence of cancer of the lung and of cancer of the urinary
bladder, with particular reference to the confounding influence of
smoking.
Smoking is the major risk factor for both lung and
bladder cancer, and i t is obvious that if the data are not
adequately adjusted for tobacco exposure, conclusions about the
risk of diesel exhaust exposure are likely to be misleading.
The
difficulties of adjusting adequately for smoking are not enough
appreciated.
Apart from any differences that exist between smokers
and nonsmokers, the number of cigarettes smoked per day, the age of
starting to smoke, the total duration of smoking, the quality of
the cigarettes smoked (notably their tar content and degree of
f i l t r a t i o n ) , and the manner of smoking may all contribute
significantly to confounding of occupational exposure by tobacco
smoke.
Table 1, i l l u s t r a t e s differences between different
occupational groups in respect to these factors.
The table shows
that the lifelong exposure to cigarette smoke of truck drivers in
particular differed strikingly from that of a l l other occupations.
Fewer truck drivers had never smoked, and of those who had smoked,
fewer had used filter-tipped cigarettes, more had smoked heavily,
and more had used high-tar cigarettes.
The result is that their
lifetime cigarette tar dosage was much higher than that of any
other occupational group.
Most studies dealing with exposure to
diesel exhaust and cancer do not have sufficient information on
smoking to permit a thorough analysis of this important factor.
Consequently, any conclusions on the risk of diesel exhaust
exposure and cancer must inevitably remain tentative.
Even studies
restricting analyses to nonsmokers, although apparently convincing,
are subject to uncertainties about the accuracy of the smoking
categorization, as well as to possible other differences between
smokers and nonsmokers.
In this evaluation, we will not deal in detail with the
problem of biases, although it" should be clearly recognized that
reports on both diesel exposure and smoking may involve different
degree of bias when replies come from patients, healthy persons,
from the subjects themselves, or from next-of-kin.
Relationship betveen diesel exhaust exposure and lung cancer
Emissions from diesel engines have been suspected of
carcinogenicity for over thirty years. Doll (14) in a valuable
review of the epidemiology of lung cancer at that time commented
that certain occupations were interesting because they did not
appear to be associated with any materially increased risk.
Foremost among these were those industries in which the employees
had a special exposure to the fumes of petrol or diesel-driven
engines.
Doll was impressed that police traffic controllers on
duty where exposures to bus and automobile exhaust fumes were high
appeared to have no excess risk of lung cancer.
In his paper, he
cited Kennaway and Kennaway (15) and the Registrar General (16),
who had shown that the drivers of horse-drawn vehicles had as high
(or higher) standardized mortality ratios for lung cancer as
drivers of motor vehicles. He noted that the retrospective studies
of lung cancer failed to provide any support for the hypothesis
(14, 17-19) , and referred to Raffle's observation (20) in the
London busmen of somewhat lower lung cancer mortality rates among
drivers and conductors and engineering staff at trolley bus depots
than of underground railway workers and engineering staff at bus
garages.
However, he noted that "these results are not of great
significance in relation to diesel engines, as these have not been
on the road in large enough numbers for diesel fumes to be expected
to have produced any evidence of cancer - even if they were capable
of doing so."
The early studies of diesel exhaust emissions (20-22) appeared
to be essentially negative, although the inadequate latency, noted
by Doll, limited conclusions from a l l these studies.
The London
Busmen study, particularly in the follow-up presented by Waller
(23), has been perhaps the most influential of these, especially in
Britain.
But i t s weaknesses, notably an incomplete follow-up,
uncertainty about the degree of exposure to diesel emissions, and
the lack of any smoking information leave one in considerable
doubt.
Heuper (24) noted high lung cancer death rates among
transportation workers, which he attributed to exposure to exhausts
from gasoline and diesel engines, to petroleum lubricants, and to
dust from asphalt roads.
He commented that 75% of the lung cancer
deaths of transport workers occurred among railroad workers, who
constituted only 25% of the group.
The basis for this statement is
not clear.
Interest has continued to focus on transportation workers.
Hannunkari and co-workers (25) examined mortality and disability in
railroad workers in Finland^
They reported that mortality rates
for malignant tumors were higher among engineers than among
trainmen or clerks.
I t i s not clear how these subgroups differed
in respect to diesel exposure, and no allowance was made for any
potentially confounding factors, such as smoking or social c l a s s .
Howe and co-workers (26) reported on the mortality of 43,826
pensioners of the Canadian National Railroad Company from 1965 to
1977.
Exposure to diesel fumes was based on the job held
immediately before retirement.
Three categories of exposure were
used: not exposed, possibly exposed, and probably exposed.
Mo
attempt was made to validate these categories, and no measurements
of diesel exposure were made.
A gradient of risk of lung cancer
was observed, from 1.00 in those considered not exposed, through
1.20 in those possibly exposed, to 1.30 in those probably exposed.
A similar gradient was reported for exposure to coal dust, which,
the authors comment, would be expected since those now exposed to
diesel fumes would in the past have been exposed to coal dust.
Slacking histories were not available, but the authors maintain that
smoking could not completely explain their findings.
Their reason
is not, however, convincing, particularly since the mortality rates
for emphysema, a fatal disease most strongly related to smoking,
were strongly related to the diesel exposure categories.
In the united States, Schenker and co-workers (27) published
the results of a pilot study of American railroad workers, in which
2519 male railroad workers aged 45 to 64 with 10 or more years of
service on the railroads were selected on the basis of their job
classifications.
Cause specific mortality was established for
those who had.died by 1979.
Employees considered to be exposed to
diesel fumes had a relative risk of lung cancer of 1.42 (95% CI:
0.45 to 2.39) compared with those not so exposed.
No allowance was
made for smoking in this study.
Further studies of the US railroad industry have been
published by Garshick and co-workers (28, 2 9 ) . In the first of
these, 15,059 deaths, which occurred among 650,000 railroad workers
between March 1, 1981 and February 28, 1982, were studied.
certificates were obtained for 87% of these deaths.
Death
There were
8
1256 deaths from lung cancer.
These deaths were compared with two
decedent controls, which were randomly chosen from all deaths that
did not mention cancer anywhere on the death certificate and that
were not due to suicide, accident, or unknown causes.
Smoking
habits and residential histories were obtained for cases and
controls by mailed questionnaires or telephone from the next of
kin.
Occupational histories were determined from yearly job
reports available to the Railroad Retirement Board.
Personal
exposures were assessed for men in 39 job categories in 4
railroads.
Particulate exposures ranged from 9 to 76 ug/m
for
clerks and station agents (considered to be not exposed) to 83 to
168 ug/m
for all diesel-exposed groups and from 87 to 322 ug/m
for shopworkers.
The results were presented separately for men
under 65 years of age and for men aged 65 and over.
A clear and
consistent effect of cigarette smoking on lung cancer was seen in
each age group, but a weak effect of diesel exposure was seen only
in the younger men.
There was no effect in the older men.
The
authors summarize the findings: "using multiple conditional
logistic regression analysis to adjust for smoking and asbestos
exposure, workers aged 64 years of age or younger at the time of
death with work in diesel exhaust exposed jobs for 20 years or more
had a significantly increased relative odds (OR=1.41, 95%
1.88).
CI=1.06,
No effect of diesel exhaust exposure was seen in men aged
65 and over."
The authors claim that "roughly half of the older
workers were unexposed to diesel exhaust and that those exposed had
a short duration of exposure."
This claim is unconvincing on the
basis of the figures presented and could be influenced by the
classification of those employed before 1959, who were considered
to be unexposed.
Moreover, there were only 9 nonsmokers among the
younger cancer cases, which together with smoking information from
next of kin must raise questions about the adequacy of allowance
for smoking.
In the second paper by Garshick and co-workers (29) , a cohort
of 55,407 white male railroad workers, aged 40 to 64 years in 1959,
who started to work for the railroad 10 to 20 years earlier, was
selected on the basis of the job held in 1959.
followed to December 31, 1980.
The cohort was
By that time 19,396 deaths had been
reported to the Railroad Retirement Board (RRB).
certificates were obtained for 17,120 (88.3%).
Death
Of these, 1,694
(8.7%) were attributed to lung cancer (ICD-8: 162) .
Diesel
exposure was assessed on the basis of annual job codes, reported to
the RRB.
Workers with potential asbestos exposure were excluded.
Analytic methods were complicated and difficult to understand.
Directly standardized ratios for deaths from lung cancer in dieselexposed and unexposed workers were computed for 5-year age groups.
In addition, a number of proportional hazard models, time dependent
and non-time dependent, were examined.
Relative risk of diesel
exposure adjusted for age was 1.45 for men aged 40 to 44 and
declined to 0.98 for men aged 60 to 64.
The term time-dependent
model seems to refer to the inclusion or exclusion of the last 5
years of life.
If these years were included in the estimates of
exposure, there was no evidence of a consistent exposure-duration
response relationship.
With recent exposure excluded, however, the
authors were able to produce some statistically significant
10
relationships, of which, a relative risk of 1.72 (95% CI:
1.27/2.33) for men with 15 years or more exposure might be cited.
The main weakness of this paper, apart from the complexity of the
analysis, is the lack of any allowance for smoking.
The authors
have considered the possibility that excess risk of diesel exposure
could be due to differences in smoking habits between dieselexposed and unexposed groups, but they have rejected this because
they say they found no such differences in a group of 517 railroad
workers whom they had surveyed in 1982 for past asbestos exposure.
They concluded that occupational exposure to diesel exhaust is
associated with a modest excess risk of lung cancer.
Members of a heavy construction equipment operators union were
studied by Wong and co-workers (30) . The mortality of 34,156 male
union members was compared with that of all white males in the
United States. The Standardized Mortality Ratio (SMR) for all
causes of death was 81, while that for lung cancer was 99. A
significantly high ratio of 167 was observed for liver cancer.
The
risk of lung cancer increased as the interval between the time of
first exposure in the industry and the time of death increased.
A
significantly increased SMR for lung cancer was observed among
those who had retired, and the SMR remained elevated when those who
had retired early were excluded.
The reason for this elevated SMR
is not clear. No striking relationship with diesel exhaust
exposure and lung cancer was observed.
In fact one of the more
interesting observations in this study was that lung cancer SMRs
were low in all those occupations believed to result in high diesel
emission exposures, such as scraper, loader, dozer, or backhoe
11
operator.
This study lacks any smoking information.
To the extent
it provides any sound basis for categorizing diesel exposures, its
findings do not suggest there was much risk of lung cancer from
diesel exhaust emissions.
Boffetta and co-workers (31) reported an analysis of 2-year
mortality of 461,981 men aged 40 to 79 enrolled in the American
Cancer Society's prospective study, in relation to occupations with
likely diesel exhaust exposure.
They observed a relative risk
adjusted for smoking of 1.05 (0.97, 1.13) for all causes of death
and of 1.18 (0.97,1.44) for lung cancer.
A dose-response effect
was observed, the risks being 0.94 for all causes of death and 1.05
for lung cancer in those with 1 to 15 years exposure, compared with
1.09 and 1.21 in those with 16 years exposure and over,
respectively.
Railroad workers, heavy equipment operators, miners,
and truck drivers had higher mortality rates both from all causes
and from lung cancer when compared with subjects with other
occupations and no exposure to diesel emissions.
However, truck
drivers who were exposed to diesel emissions were not at any
increased risk of lung cancer when compared with truck drivers who
were not exposed to diesel emissions.
This suggests that
differences other than diesel exposure may have been responsible
for the difference in risk of lung cancer between truck drivers and
other men.
It is interesting to note in this paper that among men
classified as having increased diesel exposure significantly raised
relative risks were observed for cerebrovascular disease (1.61),
arteriosclerosis (3.12) , pneumonia and influenza (1.97) , cirrhosis
12
of the liver (1.79), accidents (1.56), and ill-defined conditions
(3.44) .
The importance of allowing adequately for smoking in assessing
the risk of diesel exhaust exposures was illustrated in a casecontrol study conducted by Hall and Wynder (32) that compared 502
lung cancer cases with 502 controls matched for age, race,
hospital, and time of admission.
The groups were interviewed for
smoking, alcohol *nd coffee consumption, use of artificial
sweeteners, occupations held, occupational exposures, and other
demographic variables.
The expected strong relationship between
cigarette smoking and lung cancer was observed.
A two-fold
increased risk was also observed in those who were exposed to
diesel exhaust when no allowance was made for smoking. When due
allowance for smoking was made, the excess risk was reduced, and
the excess was no longer statistically significant (OR: 1.4,
CI:0.8, 2.4). In this study the relative risk of nonsmokers and
ex-smokers, combined because of small numbers, was also modestly
raised (OR: 1.46 ,CI:O.9 ,2 .3) . In a further study from the American
Health Foundation, Boffetta and co-workers (33) compared 2584 lung
cancer cases with 5099 hospital controls.
The crude odds ratio for
those considered probably exposed to diesel exhaust was 1.31 (1.09,
1.57), but when adjustment for smoking and other confounders was
made, the estimate was reduced to 0.95 (0.78,1.16).
Similar
results were obtained for truck drivers, which was the only
occupational category large enough for separate analysis. An
interesting, additional feature of this study was that when selfreported exposures to diesel emissions were used, rather than more
13
objective estimates derived from occupations held, the crude odds
ratio of 1.45 (0.93, 2.27)
was reduced to 1.21 (0.78, 2.02),
suggesting the possibility of some reporting bias.
Steenland and co-workers (34) studied male decedents from the
Central States files of the Teamsters union.
There were 10,699
deaths in 1982 and 1983 among men who had filed claims for pension
benefits, which requires 20 years tenure in the union.
certificates were obtained for 10,485 (98%).
Death
Cases were all deaths
from lung cancer (ICD 162,163), either underlying or contributory.
Controls were a systematic one in six samples of all 10,485 social
security numbers, excluding deaths from lung or bladder cancer and
motor vehicle accidents.
1452 controls.
There were 1288 lung cancer cases and
Occupational histories were obtained from Teamster
Union records and supplemented by information obtained from the
next of kin.
The data were analysed separately for each source.
Information on smoking and other confounding factors, such as diet
and asbestos exposure, was obtained from the next of kin.
Interviews were conducted with the next of kin of 1085 (82%) cases
and 1160 (80%) of the controls.
After excluding missing
information, 77% of the cases and 75% of the controls were
available for analysis of occupation using Teamster records, and
68% of the cases and 66% of the controls using next of kin data.
Men were classified according to the job category in which they had
worked longest (from the next of kin: gasoline truck driver, diesel
truck driver, driver of both types of truck, truck mechanic and
dock worker; from the Teamster work histories: long-haul, shorthaul, or city drivers, truck mechanics and dock workers).
Men who
14
had never worked in any of these job categories were classified as
nonexposed, or as men who had held other jobs with potential diesel
exposure.
Several job categories had raised lung cancer risks
compared with unexposed workers, but none of the differences was
statistically significant.
However, based on the Teamster history,
a significant positive trend was observed with increasing years of
employment as a long-haul truck driver after 1959 or 1964. Based
on the next of kin history, men whc primarily drove diesel trucks
showed a similar increasing lung cancer risk with increasing
duration of employment; but the trend was not statistically
significant, (p=0.12).
Long-term drivers of primarily diesel
trucks had an odds ratio of 1.89 (1.04, 3.42).
The authors have
concluded that their results suggest that some types of truck
drivers have an increased risk of lung cancer.
This excess may be
confined to truck driving after 1959 and specifically to diesel
trucks.
However, they point out that the exposures of truck
drivers are unknown and that no measurements were made in this
study.
This is one of the increasing number of papers being published
nowadays in which the reader has no chance of following and
checking the analysis. The crude odds ratios are strikingly
different from those presented in Table 3, presumably because of
the allowances incorporated for age and cigarette smoking.
But no
data are presented on either of these crucial factors. So the
reader has to take what he is told on trust.
The main reservation
to accepting the findings in this study, however, stem from the
15
difficulty of obtaining adequately detailed and unbiased smoking
habits from next of kin.
Hayes and co-workers (35) studied the association between
employment in motor exhaust-related occupations and lung cancer in
three case-control studies carried out by the National Cancer
Institute between 1976 and 1983 in Florida, Louisiana, and New
Jersey.
In all, there were 2291 cases of lung cancer and 2570
controls. Cases and controls were either all male (Florida and New
Jersey) or matched for age (Louisiana) . Most of the analyses were
limited to subjects who had been personally interviewed.
For those
with 10 or more years in motor exhaust-related occupations (MER) ,
the age, smoking and study related adjusted odds ratio for lung
cancer was 1.5: (95% CXtl.2-1.9).
The risk was raised for both
truck drivers and other MER occupations (truck drivers OR: 1.5, 95%
CI: 1.1,1.9; other occupations OR: 1.4, 95% CI:1.1,2.0).
The 50%
increase in risk was not due to differences in race or exposure to
recognized carcinogens between the groups and could not be
explained by the greater use of cigarettes or by other occupational
exposures. The authors were unable to evaluate whether diesel or
gasoline engine exposures were more strongly related to the
elevated risk observed.
The greater risk of lung cancer among those in MER occupations
shown in this study is persuasive.
Occupations seem to have been
as well categorized as is possible in personal interviews.
The
categorization of smoking habits, however, seems to have been
limited to stated cigarettes per day, which we have already
suggested is not really adequate to exclude differences between
16
groups.
Nevertheless, the observation that an increased risk of
lung cancer was present even in nonsmokers provides some evidence
that the excess risk was not entirely due to cigarette smoking.
Questions about the accuracy of reporting of not smoking, less
accurate than is often thought, or of bias between cases and
controls, remain as potential sources of error.
This study should be considered in the light of the study by
Siemiatycki and co-workers (36) . This comprised a populationbased, case-referent study of 3726 cancer patients, aged 30 to 70,
in 19 Montreal hospitals. For each cancer site, a reference group
was selected from other cancer patients.
The odds ratio of
patients with squamous cell lung cancer who were categorized as
exposed to gasoline exhaust was modestly increased (OR: 1.2, 90%
CI:1.0, 1.4). The odds ratio of those exposed to diesel exhaust
was similar (OR: 1.2, 90% CI: 1.0,1.5).
Thus, in this study, it
appeared that a small increase in lung cancer risk might result
from either exposure to gasoline or to diesel emissions. However,
the validity of categorization into gasoline or diesel exposed may
be open to question.
No allowance for cigarette smoking was made
in this study.
Benamou and co-workers (37) analysed occupational exposures in
relation to lung cancer in the French component of the
international lung cancer case-control study (38) . In this study,
1625 histologically-confirmed cases of lung cancer and 3091
controls, matched for age, sex, hospital admission, and
interviewer, were available and 1334 cases (82.1%) and 2409
controls (77.9%) were compared.
Information was collected by
17
questionnaire on smoking, drinking, occupation, and residence. A
complete occupational history was taken.
Since most women had no
occupation (sic) and few men had smoked cigars and pipes, the
results were limited to male nonsmokers or exclusively cigarette
smokers.
An excess risk was observed in those classified as
transport equipment operators among motor vehicle drivers
(International code 985). After adjusting for cigarette smoking,
the odds ratio was 1.42, CI:1.07,1.89) . There was no evidence of
an increasing risk with increasing duration of exposure, nor was
any significant interaction of occupation and smoking found,
although the evidence for these two statements is not given.
Additional papers on diesel exhaust emissions in relation to
lung cancer are summarised in Table 2 (39-46, 48-53).
The table
shows that many papers reporting significantly increased risks of
lung cancer among diesel-exposed workers have often failed to allow
for differences in cigarette smoking between the groups. Several
studies have shown raised risks when a crude analysis of the data
is carried out, but little or no increased risk when the analysis
is refined.
In some studies in which the risk persists,
comparisons within the occupational group have failed to reveal a
dose-response relationship.
This suggests that some characteristic
other than exposure to diesel emissions may differentiate the
groups.
It should not be concluded from this table that where we
have checked that allowance for cigarette smoking was made, it
necessarily implies that the allowance was adequate.
Indeed, as we
have already indicated, a better case can usually be made for the
view that it was not. Our present thinking is that inadequate
18
control of confounding by smoking together with conscious or
unconscious bias in reporting could easily explain the relatively
small risks now often alledged to be due to exposure to diesel
exhaust emissions
Relationship of diesel exhaust exposure to bladder cancer
Apart from cancer of the lung, there has been considerable
concern during the past decade that exposure to diesel exhaust
emissions might also cause cancer of the bladder.
Milham (44),
reviewing occupational mortality for the State of Washington,
observed elevated proportional mortality ratios for bladder cancer
among gas station workers, fuel o i l dealers, garage owners, auto
mechanics, fuel o i l or gasoline truckers, taxicab d r i v e r s , truck
drivers and deliverymen.
review.
No allowance for smoking was made in this
However, in a study of 24,416 persons admitted to Roswell
Park Memorial I n s t i t u t e between 1956 and 1965, Decoufle and coworkers (40) found that after allowing for smoking, there was a
modestly increased risk of lung cancer among railroad engineers and
firemen and bus- truck- and taxi-drivers;
Neither of the two prospective studies of lung cancer
conducted on railroad workers in Canada or the United States has
provided any evidence on the risk of bladder cancer among workers
exposed to diesel exhaust emissions.
In the analysis of diesel
exhaust exposed occupations among men enrolled in the American
Cancer Society's prospective study, referred to earlier (31) , no
particular comment was made on bladder cancer.
Table 9 from the
19
paper by Boffetta et al.(31), shows that there were 13 deaths from
bladder cancer during the two-year period considered.
This gives a
relative risk adjusted for age, smoking and other occupational
exposures of 1.04, which was insignificantly different from unity
and does not suggest much increased risk of bladder cancer from
diesel exhaust emissions.
The number of bladder cancer cases,
however, was small, and further analysis of this exposure subgroup
after a longer period than two years would be valuable.
In the study of heavy equipment operators carried out by Wong
and co-workers (30) , the standardized mortality ratios of those
having high and low diesel exhaust exposure were almost identical.
A large population-based, case-control study of 480 male and
152 female bladder cancer cases was carried out by Howe and
coworkers (54) in Canada.
A strong effect of cigarette smoking was
reported with lower risks in smokers using filter-tip cigarettes.
Increased risks were also found in chemical, rubber, photographic,
petroleum, medical and food processing industries among men, and in
persons exposed to fumes and dust of either sex.
Railroad workers
and those exposed to diesel and traffic fumes were two groups with
increased risks.
The authors suggested that this excess risk was
most likely to have been due to hydrocarbons in the form of fuel
and lubricating oils. Increased risks were also found from coffee
drinking and from the use of private water supplies.
Two studies, based on the National Cancer Institute's bladder
cancer case-control study (55) have been published (56, 57).
Silverman and co-workers (56) compared 303 white male bladder
cancer cases with 296 age-matched controls from the general
20
study area in D e t r o i t .
In both these s t u d i e s , cases aged 21 to 84
were identified through the Surveillance Epidemiology and End
Results (SEER) R e g i s t r i e s .
Controls under 65 years were obtained
by random-digit d i a l i n g , and controls aged 65 and over from the
Health Care Financing Administration's population
lists.
Information was c o l l e c t e d in personal interviews on occupations
held and possible exposures, smoking h a b i t s , c o f f e e consumption,
a r t i f i c i a l sweetener and hair dye use, and other medical d e t a i l s .
The trucking service industry was the only industry with an
increased risk of bladder cancer (OR: 2.2 CI: 1 . 1 , 4 . 4 ) .
This
appears to be a crude r a t i o , unadjusted for smoking, and no
evidence i s given that enables the reader to do the adjustment.
Within the trucking service industry, s i g n i f i c a n t l y raised risks
were found for truck drivers (OR: 2 . 5 , CI: 1 . 4 , 4 . 4 ) and
i n s i g n i f i c a n t l y raised risks for deliverymen, OR: 1 . 6 , CI:
0 . 9 , 2 . 6 ) , bus drivers (OR: 1 . 5 , CI: 0 . 4 , 5 . 3 ) , and taxicab drivers
and chauffeurs (OR: 2.0,CI: 0 . 7 , 5 . 4 ) .
The crude relative risk of
2.5 in the truck drivers was reduced to 2.1 after adjustment for
age and cigarette smoking.
I t i s not c l e a r whether this remained
s i g n i f i c a n t l y elevated since the e f f e c t on the confidence intervals
i s not given.
The risk increased with duration of exposure.
Truck drivers who reported operating v e h i c l e s with d i e s e l engines
had a particularly high risk
(RR:
1 1 . 9 , 95% C I : 2 . 3 , 61.1).
In a later paper (57) , a l l 1909 white male bladder cancer
cases and 3569 population-based controls seen during a one-year
period during 1977 and 1978 were compared
S t r a t i f i c a t i o n of the
r e s u l t s was by age, smoking, c o f f e e drinking, employment in other
21
motor exhaust occupations, occupational exposure to known high risk
substances, occurrence of urinary tract infections, urbanization
and geographical area.
Truck drivers or deliverymen, taxicab
drivers or chauffeurs, and bus drivers had raised risks of bladder
cancer.
The risks were higher in those reporting the occupation as
their usual occupation than in those who reported ever being so
employed.
For truck drivers and deliverymen usually so employed,
the excess risk was 50%, (OR: 1.5, CI: 1.1,2.0).
There was a
rather consistent trend of increasing risk among those who reported
ever being a truck driver or deliveryman.
Both of these studies have potential sources of bias.
The
proportions of bladder cancer cases inteviewed was lower than that
of the controls, and the proportion of proxy interviews was
correspondingly higher for the cases than for the controls.
Ascertainment bias is always a worry in retrospective studies of
this kind since an expected hazard may be more readily reported by
proxies.
Stratification by so many factors must have been a very
difficult task.
Its adequacy may be questioned.
There is also
uncertainty about the degree of exposure of truck drivers to diesel
fumes.
Some objective measurement of this is badly needed.
In a further study of bladder cancer, Hoar and Hoover (58)
compared cases and controls who had died in Vermont and New
Hampshire during 1975 to 1979.
Information was obtained by
personal interviews from the next of kin.
An increased risk of
bladder cancer among truck drivers was found , (OR: 1.5, 95% CI:
0.9, 2.6). The increased risk was unaffected by allowance for
smoking and coffee drinking.
It is not clear how this allowance
22
was made and the problems of ascertainment bias in this study are
serious.
Wynder and co-workers (59) compared 194 histologically
confirmed bladder cancer cases in 26 hospitals with 582 controls,
matched for age, sex, race, hospital, and time of admission.
Standardized interviews were obtained on smoking, occupation,
coffee and alcohol ingestion and other factors
admission.
at the time of
The risk of bladder cancer among cigarette smokers was
found as expected.
There was also an increased risk among those
patients who were categorized as having high exposure to diesel
exhaust emissions (OR: 1.68; 95%CI: 0.49,5.73).
This excess was
completely eliminated by adequate allowance for cigarette smoking.
In a later study from the American Health Foundation, Iyer and
co-workers (60) confirmed an apparently increased risk of bladder
cancer from exposure to diesel exhaust emissions.
In this study
crude odds ratio among the diesel exposed group was 1.40, but after
allowing for cigarette smoking, the estimate was reduced to 1.2,
with 95% CI:0.8, 2.0.
Risch and co-workers (61) compared 825 cases of bladder
cancer, occurring during the period 1977 to 1982 in four Provinces
in Canada, with randomly selected population controls.
The
histologically verified cases of bladder cancer were individually
matched by age, sex, and area of residence with 792 controls.
Lifelong occupational and residential histories, past medical
experience, intake of certain dietary items, and exposure to
tobacco and certain other l i f e style factors was obtained by
interviewing the participants in their homes.
Analysis was by
23
conditional, logistic regression.
After allowing for smoking, most
occupational factors examined were not associated with
significantly increased risk of bladder cancer.
For exposures
between eight and twenty eight years before diagnosis, however, men
employed for six months or more as t a i l o r s , or in jobs in chemicals
and dyeing, pr exposed to tars or asphalt, or in jobs having
exposure to diesel or traffic fumes had raised r i s k s .
fumes, the odds ratio was 1.68, (p=0.0008) .
exposures to such fumes were differentiated
I t is not clear if the
from exposures to tars
and asphalts, nor if diesel fumes were differentiated
fumes.
For diesel
from traffic
The authors concluded that jobs having exposure to diesel
or traffic fumes appeared to convey s l i g h t l y increased r i s k s .
There has been interest in bladder cancer in Denmark for many
years.
Clemmesen was interested in the association between lung
and bladder cancer and devoted one volume of his s t a t i s t i c a l
studies to bladder cancer (62) .
A comprehensive review of the
state of knowledge on bladder cancer was carried out by Lockwood
(63).
In addition to his excellent review, Lockwood carried out a
case-control study in which he compared 369 bladder cancer patients
in Kobenhaven, Frederiksberg, with 369 controls (63). One
observation is relevant to our present concern.
Lockwood reported
that there were 14 bladder cancer cases among persons working on
railways and tramways, whereas 7.9 cases might have been expected.
This gives an excess risk of approximately 1.8.
Since the use of
diesel trains and trams in Denmark before 1960 must have been
infrequent and of short duration, i t seems unlikely that exposure
to diesel emissions could have had anything to do with this excess
24
risk and supports the view that there might be other differences
between railway and tram workers to account for an increased cancer
risk.
Jensen and co-workers (64) compared 371 bladder cancer cases
with 771 controls, drawn at random from the general community.
Previous papers have focussed on smoking, coffee and other beverage
consumption.
This one presents their findings on drivers,
painters, and certain other occupations.
After adjustment for age
and tobacco smoking, there was an increased risk of bladder cancer
in those men engaged in land transport, in particular bus, taxi, or
truck driving.
Risks increased fairly consistently with increasing
duration of employment, suggesting a dose-response relationship.
Unfortunately, although adjustments were made for smoking, no
smoking data are presented in this paper, and the evidence on
smoking and occupational exposure is not shown.
There is also the
problem of rumination bias in this study, which i s inherent in a l l
comparisons of hospital p a t i e n t s , who have frequently been
questioned about their smoking habits, with healthy controls, who
may never have been asked about their smoking habits and may not be
inclined to elaborate on them.
Mommsen and co-workers (65) compared 30 determinants of
bladder cancer in 165 male bladder cancer patients with a similar
number of controls living in a predominantly rural area of Denmark.
They reported a significantly increased relative risk associated
with cigarette smoking, a history of prostatic surgery, nocturian
previous venerial disease, and certain industrial exposures,
specifically to o i l , gasoline and certain unspecified chemicals.
25
An insignificantly raised odds ratio was also noted for those with
a history of working with petroleum and asphalt.
The significance
of these occupational exposures, however, is questionable since no
allowance seems to have been made for smoking.
In Germany, Franzel-Beyme and co-workers (66) compared 531
male bladder cancer patients with 531 matched hospital controls.
An increased risk was observed in several occupational sub-groups.
The risk was increased in long-distance truck drivers (OR: 1.79,
CI: 1.12, 2.83).
There was no increase in risk with increasing
duration of truck driving.
Allowance was apparently made for
smoking but i t s adequacy is somewhat questionable.
The details are
not given in the paper.
This study needs to be read in conjunction with an earlier
publication from this group of investigators (67) , which compared
431 bladder cancer cases (340 males and 91 females) with a similar
number of controls.
A clear effect of smoking was observed, and
elevated risks were reported for those engaged in a number of
industries, notably rubber, p l a s t i c s , dye, t e x t i l e s , mining, spray
painting, coal pitch, chromium and zinc.
After allowing for
smoking, an increased risk of those drinking more than 4 cups of
coffee daily, half to one l i t e r of beer daily, or high-proof
s p i r i t s was noted.
Frequent consumption of canned food and fatty
meals were associated with higher r i s k s .
A highly significant odds
ratio of 4.9 was found for a daily fluid intake of more than 2
liters.
The relation of this report to that on the long distance
truck drivers is not clear, but presumably both involve the same
population and there was considerable overlap.
I t is hard to
26
interpret so many positive associations, which may be confounded to
a varying degree.
Iscovitch and co-workers (68) carried out a case-control study
of bladder cancer in the Greater La Plata region of the Argentine
with 117 cases of cancer compared with 117 hospital and 117
neighbourhood controls.
A strong effect of smoking was reported.
In addition, the authors noted a remarkable effect of coffee
drinking, odds ratios of 4.45 and 12.0 being reported for those
drinking 2 cups per day and three or more cups daily.
Odds ratios
were also raised in those engaged in truck or railway work even
after allowance for smoking.
On the basis of the data presented,
i t is difficult to calculate odds ratios for occupational exposure
after allowing for smoking, since several of the cells had no cases
or controls.
In addition in assessing the effect of occupation
allowing for smoking, no allowance was made for coffee drinking.
All in a l l there seems to be considerable
potential for residual
confounding in the occupational comparisons.
Confounding of the effects of occupational exposure by
cigarette smoking i s now fairly generally recognized and has been
considered in most of the more 'recent studies of diesel exhaust.
Other personal factors, that may confound occupational assessments,
have seldom been equally thoroughly treated.
Much of the evidence
indicting diesel exhaust as a cause of lung cancer has resulted
from studies, which have found higher lung or bladder cancer risks
in truck drivers, who are then assumed to have been exposed to
diesel fumes.
However, long distance truck drivers not
surprisingly have an unusual l i f e s t y l e , spending long hours
27
driving their trucks to and fro across the continent.
We have
recently compared their l i f e style with that of more representative
samples of the population (69) .
Interviews were conducted with
truck drivers, who stopped at a truck stop in Bloomsbury, New
Jersey.
The interviews were conducted between October, 1985 and
April, 1986, when 206 truck drivers were asked a broad spectrum of
questions about their l i f e - s t y l e .
Heavy cigarette smoking and
coffee consumption were reported.
In addition, these truck drivers
reported a very high consumption of dairy products, with their
consumption of eggs, b u t t e r , margarine and cheese being far greater
than comparably aged groups in other occupations.
I t is possible
that any excess of cancer that these truckers may have could be due
more to their unusual l i f e s t y l e than to any occupational exposures.
Heavy cigarette smoking i s almost always found in studies of
bladder as well as of lung cancer and coffee drinking, although
less consistently involved, is fairly generally accepted as being
carcinogenic (70) .
Dietary fat is not yet generally agreed to play
a role in the etiology of lung or bladder cancer, although a role
of fats has been suspected by some research workers.
Bladder
cancer is rare in Japan but increases in Japanese migrants to
Hawaii.
Moreover, correlation studies between dietary fat and
bladder cancer show a moderately positive association, (p=0.58).
The views and opinions of an I ARC Working Group, which met in
Lyon, June 14-21, 1988, on the evaluation of Carcinogenic Risk to
Humans of Diesel and Gasoline Engine Exhaust and Some NitroArenes (71) have recently been published.
After reviewing the
l i t e r a t u r e , the group concluded that in humans there was limited
28
evidence for carcinogenicity of diesel engine exhaust, inadequate
evidence for the carcinogenicity of gasoline engine exhaust, and
limited evidence for the carcinogenicity of engine exhaust,
unspecified as from diesel or gasoline engines.
The group's
overall evaluation was that diesel engine exhaust was probably
carcinogenic to humans (Group 2a carcinogen) and that gasoline
exhaust was possibly carcinogenic to humans (Group 2b).
Our conclusion from the literature ih that, although the
evidence suggests that truckers and railroad workers with exposure
to diesel exhaust may have some increased risk of bladder and
possibly of lung cancer, we are not convinced that this increased
risk is due to diesel exposure, or that i t is even certainly due to
occupation.
Personal factors and other exposures have not yet been
adequately excluded.
29
ACKNOWLEDGMENTS
We are indebted to Dr. Edith Zang, Division of Epidemiology,
American Health Foundation, for preparation of Table 1. We thank
Mrs. Roz Fieland and Mrs. Clara Horn for their editorial
assistance.
31
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Luepker RVf Smith ML. Mortality in unionized truck drivers.
J Occup Med 1978; 20:677-682.
42.
Williams RRr Stengens NL, Goldsmith JR. Associations of
cancer type with occupation and industry from the Third
National Cancer Survey interview. JNCI 1977; 59:1147-1185.
43.
Ahlberg J, Ahlbom A, Lipping H. Cancer among professional
drivers. Laekartidningen 1981; 78:1545-1546.
44.
Milham S. Occupation mortality in Washington State, 1950 to
1971. Cincinnatti, Ohio. National Institute for Occupational
Safety and Health, 1983. NIOSH Publication No. 83-116.
45.
Rushton L, Alderson MR, Nagarajah CR, Epidemiological survey
of maintenance workers in London Transport Executive bus
garages and Chiswick works. Brit J Industr Med 1983; 40:340345.
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46.
Morton WE, Treyve EL. Histologie differences in occupational
r i s k s of lung cancer incidence. Am J Industr Med 1982;
3:441-457.
47.
Milne KL, Sandier DP, Everson RE et a l . Lung cancer and
occupation in Alameda County: A death c e r t i f i c a t e casecontrol study. Am J Industr Med 1983; 4:565-575.
48.
Edling C, Anjou CG, Axelson 0, et a l . Mortality among
personnel exposed to diesel exhaust.
Int Arch Occup Environ
Hlth 1987; 559-565.
49.
Lerchen ML, Wiggins CL, Samet JM. Lung cancer and occupation
in New Mexico. JNCI 1987; 79:639-645.
50.
Damber L, Larsson LG. Professional driving , smoking and lung
cancer. Brit J Industr Med 1985; 42:246-252.
51.
Buiatti E, Kriebel D, Geddes M, et a l .
A case-control study
of lung cancer in Florence, I t a l y .
1. Occupational risk
factors.
J Epid Comm Hlth 1985; 39:244-250.
52.
Gustafsson L, Wall S, Larsson LG, et a l . Mortality and cancer
incidence among Swedish dock workers. A retrospective cohort
study. Scand J Work Environ Hlth 11986; 12:22-26.
53.
Coggon D, Pannett B, Acheson ED. Use of job exposure matrix
in an occupational analysis of lung bladder cancer. JNCI
1984; 72:61-65.
54.
Howe GR, Burch JD, Miller AB, et a l . Tobacco use, occupation,
coffee, various nutrients and bladder cancer. JNCI 1980;
70:237-245.
55.
Hoover RN, Strasser PH, A r t i f i c i a l sweeteners and human
bladder cancer: Preliminary Results. Lancet 1980; 1:837-840.
56.
Silverman DT, Hoover RN, Albert S, et a l . Occupation and
cancer of the lower urinary t r a c t in D e t r o i t . JNCI 1983;
70:237-245.
57.
Silverman DT, Hoover RN, Mason TJ, et a l . Motor exhaustrelated occupations and bladder cancer. Cancer Research 1986;
46:2113-2116.
58.
Hoar SK, Hoover RN. Truck driving and bladder cancer
mortality in rural New England. JNCI 1985; 74: 771-774.
59.
Wynder EL, Dieck GS, Hall NEL, et a l . A case-control study of
diesel exposure and bladder cancer. Environ Res 1985; 37:475489.
60. Iyer V, Harris RE, Wynder EL. Diesel exhaust exposure and
bladder cancer risk. Euro J Epid 1990; 6:49-54.
35
61.
Risch HA, Burch JD, Miller AB, et al. Occupational factors
and the incidence of cancer of the bladder in Canada. Brit. J
industr. Med. 1988; 45:361-367.
62.
Clemmesen J. Statistical studies in the aetiology of
malignant neoplasms IV: Lung/Bladder ratio, Denmark 19431967. Acta Path Bact Scand Suppl 247. Kobenhaven, 1974.
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Fredricksberg: An enquiry of 369 patients and 369 controls.
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Jensen OM, Wahrendorf J, Knudsen JB, Sorensen BL, The
Copenhagen case-reference study of bladder cancer. Risks
among drivers, painters and certain other occupations. Scand
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rural district. Euro J Cancer Clin Oncol 1982; 18:1205-1210.
66.
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Blasenkrebs. Soz Praeventivmed 1989; 34:249-255.
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Claude J, Kunze E, Frentzel-Beyme R, et al. Life-style and
occupational risk factors in cancer of the lower urinary
tract. Amer J Epid 1986; 124:578-589.
68.
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occupational exposure and bladder cancer in Argentina. Int J
Cancer 1987; 40:734-740.
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Wynder EL, Miller S. Motor exhaust-related occupations and
bladder cancer. Cancer Res 1988; 48:1989-1990.
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McClellan RO and Stober W. Elsevier Science Publishers,
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71.
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humans of diesel and gasoline engine exhausts and some Nitroarenes, Lyon, 1989.
Table 1 .
Mean Age at
Diagnosis
X ± S.D.
Never
Smoked
t
Current
Smoker
Mean # Cigs/Day Mean # Yrs.
+
%
Snoking Habits by Occupational Group
S.D.
Smoked
+
S.D.
Filter
Only*
I %
Inhale
Deeply*
Mean Tar ** Lifetime Tar
Cig (mg/cig)
(kg) X
± S.D.
t s .D.
Occupation
#
Physicians
240
57.0 + 10.2 82
34.2
28
11.7
26.3 + 12.4
34.1 ± 11.4
4
14.3
7
(25.0)
12.6 ± 3.9
5.8 ± 3.7
Engineers
387
57.4 ± 9.4 118
30.5
65
16.8
25.1 ± 14.2
35.6 ± 10.9
6
9.2
13
20.0
13.5 + 4.6
5.0 ± 3.4
1642 54,2 + 9.8 422
25.7 402
24.4
28.1 + 16.5
35.0 + 10.8
70
17.4
123
30.6
13.3 + 4.7
6.4 ± 5.1
55.1 ± 10.3 318
24.4 346
26.6
26.6 ± 14.0
35.9 + 11.6
60
17.3
83
24.0
13.5 + 4.6
6.1
3571 55.6 ± 9.6 732
20.5 1247
35.0
26.3 ±14.9
37.8 ± 10.9 150
12.0
347
27.8
13.5 ± 4.8
6.7 ± 4.5
Semi-Skilled
535 55.2 ± 9.1 107
20.0 233
43.5 24.0 + 13.9
37.6 ± 11.0 24
10.3
51
21.9
13.2 ± 4.8
6.4 + 4.0
Taxi/Truck
557
78
14.0 234
41.9
27.0 + 14.4
38.6 ± 10.6
23
9.8
64
27.4
13.9 + 4.9
7.2 ± 5.0
2096 54.9 ±10.3 585
27.9 513
24.5
24.6 ± 15.0
35.2 ± 11.7
94
18.3
114
22.2
13.1 + 5.0
5.5 ± 4.3
Business
Executives
Sales/Clerical 1303
Skilled
Other
55.7 + 9.4
+ 4.3
* Current Smokers
**Latest Brand Smokeds
00
38
Table 2: Lung Cancer Risk and Employment in Occupations Associated With Exposure to Diesel Emissions
AUTHOR
DATE
Raffle (20)
1957
TYPE OF CONTROL
STUDY
SMOKING
CO
N
#OF
CASES
RELATIVE
RISK
0.4*
OCCUPATIONS
23
22
18
0.9
0.8
Bus Drivers
Engineering Staff
Bus Conductors
Probably inadequate
latency
Probably inadequate
latency
Kaplan (21 )
1959
CO
N
49
0.9
Railroad Workers
Menck & Henderson
(39)
1976
CO
N
23
109
28
46
3.4*
1.6*
1.5*
Taxi Drivers
Truck Drivers
Auto Repair
Mechanics
(excl. auto)
-
3.3
Decoufle et al. (40)
1977
ce
Y
56
8
6
1.1
1.8
0.8
Truck Drivers
Bus Drivers
Heavy Equip.
Operators
ueupker & Smith
(41)
1978
CO
N
34
1.2*
Truck Drivers and
Mechanics
Williams et al. (42)
1977
ce
Y
13
12
1.3
1.4
Truck Drivers
Railroad Workers
Waller (23)
1980
CO
N
259
59
219
0.7
0.9
0.8
Bus Drivers
Maintenance Workers
Engineers
Ahlberg, et al. (43)
1981
ce
N
154
1.6*
Truck Drivers
Milham (44)
1983
PM
N
371
72
250
1.1
Truck Drivers
Bus Drivers
Heavy Equip.
Operators
1.5*
1.4*
Rushton, et al. (45)
1983
CO
N
102
1.0
Garage Workers/
Engineers
General hands
Morton & Treyve (46)
1982
CO
N
64
1.8*
Truck Drivers
Boffetta, et al. (31)
1988
CO
Y
48
1.24
5
2.60
Truck Drivers
No D/R? meaning
Heavy Equip.
Operators
240
1.02
Boffetta, et al. (33)
1990
cc
Y
210
114
Steenland, et al. (11) 1990
cc
Y
213
Hayes, et al. (35)
cc
Y
147
14
1989
38
Milne et al. (47)
1983
cc
(deaths)
N
16
26
4
23
2
1.06
0.92
1.31
0.92
0.95
1.31
0.83
0.88
Possible exposure
at work
Probable exposure
at work
Truck Drivers
CC = Case/Control
Cell Type Analysis
Crude Analysis
Stratified Analysis
Logistic Analysis
Crude Analysis
Stratified Analysis
Logistic Analysis
Crude Analysis
Stratified Analysis
Logistic Analysis
1.55*
Long haul truck driver
with 18 yrs exposure
after 1959
Smoking habits from
next-of-kin
Linear trend
(Coef 0.027)
1.5*
Truck Drivers
Heavy Equipment
All with 10 yrs or more employm.
" " " " "
"
"
1.3
1.6
1.2
1.7
3.5*
1.6*
1.2
Bus
H
(l
"
«
Taxi, Chauffeur
Mechanics
Bus drivers
Truck drivers
Taxi drivers
U
"
«
« «
* p < 0.05
CO = Cohort
COMMENTS
PM = Proportional Mortality
N = no; Y = yes
«
»
(l
"
«
39
Adresses of authors:
Professor em. i.TT. Higgins
Dept. of Epidemiology
School of Public Health
University of Michigan
Ann Arbor, Ml
Dr. R. E. Harris
Dept. Preventive Medicine
Ohio State University
Columbus, OH 43210
Prof. Dr. E. L. Wynder
American Health Foundation
320 East 43 Street
New York, N.Y. 10017
41
Mitglieder des FAT-AK 1 'Automobil und Umwelt'
Dr. rer. nat. Norbert Pelz
Mercedes-Benz AG
Abt. EP/MVAK
70322 Stuttgart
Dr.-Ing. Norbert Metz
B M W AG
Abt. W-2
80788 München
Dr.rer.nat. Helmut König
M A N Nutzfahrzeuge AG
Abt. TVC-N
Postfach 44 0100
90206 Nürnberg
Dipl.-Chem. Heiner Winneke
Volkswagen AG
Abt. E/ZL-UW
Postfach
38463 Wolfsburg
Dipl.-Ing. Josef Rösgen
Pierburg GmbH & Co. KG
Abt. T1A
41010 Neuss
Dr. rer. nat. H. R. Pfeil
Ford Werke AG
Abt. NM/IRG-3
50725 Köln
Dr.-Ing. H. Kemman
Adam Opel AG
TEZ-Motorenversuch
65423 Rüsselsheim
Dipl.-Ing. Ulrich Dworzak
Dr.Ing.h.c.F. Porsche AG
Abt. EPL 9
71283 Weissach
Dir. Dipl.-Ing. E. Santiago
Zeuna Stärker GmbH & Co. KG
Entwicklungsleitung
86016 Augsburg
Dr. med. M. Spallek
Volkswagen AG
Gesundheitsschutz
34219 Baunatal
Dr.-Ing. Dr.med. H.-G. Grimm
Volkswagen AG
Zentrales Gesundheitswesen
38463 Wolfsburg
Professor Dr.rer.nat. Horst Klingenberg
TU 'Otto von Guericke' - Institut f. Maschinenmeßtechnik, Kolbenmaschinen und Instandhaltung
39106 Magdeburg
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Immissionssituation durch den Kraftverkehr in der Bundesrepublik Deutschland
Systematik der vorgeschlagenen Verkehrslenkungssysteme
Literaturstudie über die Beanspruchung der Fahrbahn durch schwere Kraftfahrzeuge
Unfallforschung/Westeuropäische Forschungsprogramme und ihre Ergebnisse/Eine Übersicht
Nutzen/Kosten-Untersuchungen von Verkehrssicherheitsmaßnahmen
Belastbarkeitsgrenze und Verletzungsmechanik des angegurteten Fahrzeuginsassen
Biomechanik des Fußgängerunfalls
Der Mensch als Fahrzeugführer
Güterfernverkehr auf Bundesautobahnen
Recycling im Automobilbau - Literaturstudie
Rückführung und Substitution von Kupfer im Kraftfahrzeugbereich
Der Mensch als Fahrzeugführer
Stcherheitsmaßnahmen im Straßenverkehr
Sammlung, Beschreibung und Auswahl für die Anwendung der Nutzen/Kosten-Analyse
Tierexperimentelle und epidemiologische Untersuchungen zur biologischen Wirkung von Abgasen
aus Verbrennungsmotoren (Otto- und Dieselmotoren) - Literaturstudie
Belastbarkeitsgrenzen des angegurteten Fahrzeuginsassen bei der Frontalkollision
Güterfernverkehr auf Bundesautobahnen - Ein Systemmodell, 2. Teil
Ladezustandsanzeiger für Akkumulatoren
Emission, Immission und Wirkung von Kraftfahrzeugabgasen
Sicherheitsmaßnahmen im Straßenverkehr
Ergebnisse einer Nutzen/Kosten-Analyse von ausgewählten Maßnahmen
Aluminiumverwendung im Automobilbau und Recycling
Fahrbahnbeanspruchung und Fahrsicherheit ungelenkter Dreiachsaggregate in engen Kurven
Umskalierung von Verletzungsdaten nach AIS - 80 (Anhang zu Schrift Nr. 15)
Grundlagen und Möglichkeiten der Nutzung sprachlicher Informationssysteme im Kraftfahrzeug
Altteileverwendung im Automobilbau
Energie für den Verkehr - Eine systemanalytische Untersuchung der langfristigen Perspektiven
des Verkehrssektors in der Bundesrepublik Deutschland und dessen Versorgung mit Kraftstoffen
im energiewirtschaftlichen Wettbewerb Wirtschaftlichkeit des Einsatzes von Aluminium im Lkw-Bau
Äußere Sicherheit von Lkws und Anhängern
Dämpfung und Tilgung von Torsionsschwingungen im Triebstrang von Kraftfahrzeugen
Wirkungsgradmessung an Getrieben und Getriebeelementen
Fahrverhalten von Lastzügen und hierbei insbesondere von Anhängern
Entwicklung, Aufbau und Test eines Ladezustandsanzeigegerätes für Bleiakkumulatoren
in Elektrostraßenfahrzeugen
Rollwiderstand und Lenkwilligkeit von Mehrachsanhängern mit Zwillings- und Einzelbereifung
Fußgängerschutz am Pkw - Ergebnisse mathematischer Simulation Verfahren zur Analyse von Unfallursachen - Definitionen, Erfassung und Bewertung von Datenquellen Untersuchungen über kraftstoffsparende Investitionsmaßnahmen im Straßenbau
Belastbarkeitsgrenzen und Verletzungsmechanik der angegurteten Fahrzeuginsassen beim Seitenaufprall.
Phase I: Kinematik und Belastungen im Vergleich Dummy/Leiche
Konstruktive Einflüsse auf das Fahrverhalten von Lastzügen
Studie über Energieeinsparungsgeräte zur Mitführung im Kraftfahrzeug (Bordlader)
Grundlagen und Möglichkeiten der Nutzung sprachlicher Informationssysteme im Kraftfahrzeug
- Hauptstudie Sprachausgaben im Kraftfahrzeug - Ein Handbuch für Anwender Auswertung von Forschungsberichten über:
Die Auswirkung der Nutzfahrzeugkonstruktion auf die Straßenbeanspruchung
Fußgängersicherheit - Ergebnisse eines Symposiums über konstruktive Maßnahmen am Auto Auswirkungen der Nutzfahrzeugkonstruktion auf die Straßenbeanspruchung - Gesamtbericht Sprachliche Informationssysteme und Anwendungsmöglichkeiten im Kraftfahrzeug
- Ergebnisse eines Symposiums Abgasemissions- und Kraftstoffverbrauchsprognosen für den Pkw-Verkehr in der Bundesrepublik
Deutschland im Zeitraum von 1970 bis 2000 auf der Basis verschiedener Grenzwertsituationen
Bewertung von Personenverkehrssystemen - Systemanalytische Untersuchungen von Angebotsund Nachfrageelementen einschließlich ihrer Wechselwirkungen Nutzen/Kosten-Analyse für einen Pkw-Frontunterfahrschutz an Nutzfahrzeugen
Radlastschwankungen und dynamische Seitenkräfte bei zwillingsbereiften Achsen
Studie über die Wirtschaftlichkeit von Verbundwerkstoffen mit Aluminiummatrix im Nutzfahrzeugbau
Rechnerische Simulation des dynamischen Verhaltens von nicht stationär betriebenen Antrieben
und Antriebselementen
Simulationsmodell - Schwingungsprogramm zur Ermittlung der Beanspruchung von Antriebssträngen Verwendung von Kunststoff im Automobil und Wiederverwertungsmöglichkeiten
Entwicklung eines hochgenauen, normfähigen Verfahrens zur Wirkungsgradmessung an Antriebselementen
Erhebung und Auswertung von Straßenverkehrsunfalldaten in der Bundesrepublik Deutschland Ergebnisse eines VDA/FAT-Fachgesprächs
Untersuchungen zur subakuten und chronischen Wirkung von Ottomotorabgasen auf den Säugetierorganismus
Pilotzelle zur Steuerung von Batterien in Fahrzeugen mit Elektro- oder Elektro-Hybrid-Antrieb
Wirkungen von Automobilabgas und seiner Inhaltsstoffe auf Pflanzen - Literaturstudie Rekonstruktionen von fünf realen Seitenkollisions-Unfällen - Ergänzende Auswertung der KOB-Daten Luftqualität in Fahrgasträumen
Belastbarkeitsgrenzen und Verletzungsmechanik des angegurteten Pkw-Insassen beim Seitenaufprall
Phase II: Ansätze für Verletzungsprädiktionen
Erhebung und Analyse von Pkw-Fahrleistungsdaten mit Hilfe eines mobilen Datenerfassungssystems
- Methodische und meßtechnische Ansätze für eine Pilotstudie Technische Erfahrungen und Entwicklungsmöglichkeiten bei Sicherheitsgurten im Fond von Pkw
- Ergebnisse eines Symposiums Untersuchungen über Wirkungen von Automobilabgas auf pflanzliche Bioindikatoren
im Umfeld einer verkehrsreichen Straße in einem Waldschadensgebiet
Sicherheitsorientierte Bewertung von Anzeige- und Bedienungselementen in Kraftfahrzeugen - Grundlagen Quantifizierung der Radlastdynamik bei Einfach-, Doppel- und Dreifachachsen in Abhängigkeit
vom Federungs- und Dämpfungssystem des Fahrzeugs
Seitenverkleidung am Lkw - Technische Analyse
Vorstudie für die Durchführung von Tracermessungen zur Bestimmung von Immissionskonzentrationen
durch Automobilabgase
Untersuchung fahrdynamischer Eigenschaften kurzgekuppelter Lastzüge bei Kursänderungen
Abschlußbericht der Pilotstudie zum Fahrleistungspanel „Autofahren in Deutschland"
Herstellung und Analyse charakteristischer Abgaskondensate von Verbrennungsmotoren
für die Untersuchung ihrer biologischen Wirkung bei nichtinhalativen Tests
Bewertung von Personenverkehrssystemen Teil II: Auswirkungen aus Angebots- und Nachfrageänderungen im Personenverkehr
vergriffen
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Untersuchung über das Emissionsverhalten der Leichtmüllfraktion aus Autoshredderanlagen
beim Verbrennen
Verletzungsfolgekosten nach Straßenverkehrsunfällen
Sicherheitsorientierte Bewertung von Anzeige- und Bedienelementen in Kraftfahrzeugen
- Empirische Ergebnisse Retrospektive Untersuchung über die innere Sicherheit von Lkw-Fahrerhäusern
Aufbau und Labortest eines wartungsarmen, sich selbst überwachenden Batterieaggregates
für Strafîenfahrzeuge mit Elektro- und Elektro-Hybrid-Antrieb - Vorbereitende Untersuchungen Belastungsgrenze und Verletzungsmechanik des angegurteten Pkw-Insassen beim 90 -Seitenaufprall Phase III: Vertiefende Analyse der überarbeiteten und zum Teil neu berechneten HeidelbergerSeitenaufprall-Daten
Ermittlung von ertragbaren Schnittkräften für die betriebsfeste Bemessung «on Punktschweißverbindungen
im Automobilbau
Verhalten des EUROSID beim 90°-Seitenaufprall im Vergleich zu PMTO sowie US-SID, HYBRID II und APROD
Demontagefreundliche Gestaltung von Automobilien - Teil I
Grundlagenuntersuchung zum Einfluß der Sonneneinstrahlung auf die thermische Behaglichkeit
in Kraftfahrzeugen
Einsatz von Retardern in der Betriebsbremsanlage von Nutzfahrzeugen - Zweiachsiges Fahrzeug Zwei Bände
Belastungen und Verhalten des EUROSID bei unterschiedlichen Prüfverfahren zum Seitenaufprall
Kosten einer kontinuierlichen Pkw-Fahrleistungserhebung
Auswirkungen der Nutzfahrzeugkonstruktion auf die Straßenbeanspruchung
Seitenkräfte an Mehrfachachsen von Sattelanhängern bei Kurvenfahrt und durch Spurrinnen
Verfahren zur Umwandlung polymerer Mischabfälle aus der Autositz-Produktion in Polyole
Methoden zur Vorausberechnung der Faserorientierung beim Pressen von SMC mit geschnittenen Glasfasern
Teil I: Unverrippte Bauelemente
Teil II: Verrippte Bauelemente
Fahrzeugerprobung eines wartungsarmen Batterieaggregates
Grundsatzuntersuchungen zum Festigkeitsverhalten von Durchsetzfügeverbindungen aus Stahl
Fahrverhalten von Lkw mit Zentralachsanhängern
Der Fahrer als adaptiver Regler
Einfluß realer Betriebsverhältnisse auf die Reproduzierbarkeit von Wirkungsgradbestimmungen an nicht
stationär betriebenen Getrieben
Mobilität - Automobil - Energiebedarf
Rationalisierungspotentiale im Straßenverkehr I
Abschlußbericht „Einsatz von Retardern in der Betriebsbremsanlage von zweigliedrigen Lastzügen"
Vermessung des 50%-Hybrid III Dummy zur Ermittlung eines verbesserten Datensatzes für Crashsimulationen
Erfassung des Wissensstandes über Reifen-/Fahrbahngeräusche beim Nutzfahrzeug
Zusammenhang zwischen Wetterbedingungen und Verkehrsunfällen
Untersuchung von Unternehmensstrukturen und Bestimmung der technischen Leistungsfähigkeit moderner
Altautoverwerterbetriebe
Demontage und Verwertung von Kunststoffbauteilen aus Automobilen
Die elektromagnetische Umwelt des Kraftfahrzeugs
Einfluß der Zerspanung auf die Bauteilbetriebsfestigkeit unter Berücksichtigung des Hartdrehens
Vermessung von 5°/o-, 95%-Hybrid III und US-SID Dummies zur Ermittlung von Datensätzen für
Crashsimulationen
Antriebe für Elektrostraßenfahrzeuge
Einsatz von Retardern in der Betriebsbremsanlage von dreigliedrigen Lastzügen
Festigkeits- und Steifigkeitsverhalten von dünnen Blechen mit Sicken
Frontunterfahrschutz an Lkw
Bewertung der Aussagefähigkeit von Seitenaufprallversuchen mit Ganzfahrzeugen
Einfluß der Sonneneinstrahlung auf die thermische Behaglichkeit in Kraftfahrzeugen
Schädigungsmechanismen bei kreuzverzahnten Flanschverbindungen
Ermittlung ertragbarer Beanspruchungen am Schwerpunkt auf Basis der übertragenen Schnittgrößen
Bewertung epidemiologischer Untersuchungen über Dieselmotorabgas und Lungen- und Blasenkrebs
vergriffen
DM 90,-
DM 85
DM 90
vergriffi
DM 50
DM 110
DM 85
DM 45
DM 40
DM 30
DM
DM
DM
DM
DM
85
45
65
65
85
DM
DM
DM
DM
DM
DM
DM
60
85
75
70
25
50
50
DM
DM
DM
DM
35
50
170
95
DM
DM
DM
DM
DM
DM
DM
30
60
40
95
45
35
85
DM320
DM380
DM 25